E2839. Stroke Alert! ER Dilemma: What is Next? CT Perfusion (CTP) or Fast Brain MRI
  1. Rajshree Singh; Mercy Catholic Medical Center
  2. Ahmed Moawad; Mercy Catholic Medical Center
  3. Salama Chaker; Mercy Catholic Medical Center
  4. Mahmoud Shalaby; Mercy Catholic Medical Center
  5. Basem Jaber; Mercy Catholic Medical Center
  6. Fraser Brown; Mercy Catholic Medical Center
Review the current imaging guidelines for acute stroke, stroke protocol MRI and CTP in different neurological deficit scenarios, the role of stroke protocol in follow up treated stroke, and use of different imaging modalities in management decisions.

Educational Goals / Teaching Points
Reviewing the current imaging guidelines for acute stroke. Comparing the difference between fast MRI and CTP in diagnosis of different acute neurological deficit scenarios. Introducing the use of different imaging modalities in management decisions. Highlighting role of Fast MRI and CTP in follow up treated stroke.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Fast brain MRI protocol CTP protocol and parameters: current guidelines in stroke imaging, limitation of fast brain MRI Drawbacks and pitfalls of CTP. Different scenarios of acute neurological deficit diagnosis: accuracy of Fast MRI and CTP in stroke diagnosis, imaging in Ischemic stroke vs. Intra-cerebral hemorrhage, stroke with unknown duration “Wake-up”, transient ischemic attack. Stroke mimickers: seizures, hypoglycemia, cerebral venous thrombosis, acute multiple sclerosis flare, migraine aura, posterior fossa stroke, lacunar infarct, hyperacute infarcts. Hypoperfusion state: cardiac failure, shock, chronic carotid artery occlusion. Management of ischemic stroke: predicting outcome using imaging modalities and clinical scores Identification of final ischemic infarct core, mismatch between initial infarct core - final infarct * Ghost infarct core. Identification of ischemic salvageable tissue (Penumbra), Role of perfusion imaging (CTP and MR perfusion) * DWI in identification of penumbra, MRI vs. CTP for thrombectomy selection (DEFUSE 3 and DAWN trial), management of stroke by DWI-FLAIR mismatch vs. CTP - WAKE UP vs. EXTEND trial. Follow up stroke treatment: follow up hemorrhagic transformation, assessment of reperfusion state and infarct volume.

The pros and cons of CT perfusion. Pros: widespread availability, rapid acquisition, coat effective, wide applications in clinical trials. Cons: radiation dose is 6 times unenhanced CT brain, need for postprocessing program, and relatively lower sensitivity for hyperacute infarcts.